The Role of Probiotics in the Eradication of Helicobacter pylori and Overall Impact on Management of Peptic Ulcer: A Study Involving Patients Undergoing Triple Therapy in Bangladesh

Background Helicobacter pylori infection has been identified to cause constantly recurring inflammation, leading to gastrointestinal tract disorders, including carcinoma. The standard triple therapy (STT), used to eradicate H. pylori, includes two antimicrobials and a proton pump inhibitor for two weeks. Other drug regimens have also been developed since H. pylori exhibits antimicrobial resistance. These regimens, including probiotics, have been shown to lower adverse drug reactions (ADR), improve drug adherence, exert bacteriostatic effect, and reduce inflammation. Objective This study intended to explore probiotic intervention for improving eradication rates and mitigating adverse effects while administrating STT. Methods This prospective study was conducted from May to December, 2021, in the Department of Gastroenterology of Ship International Hospital, Dhaka, Bangladesh, to observe the effects of probiotics inclusion along with STT on H. pylori eradication. A total of 100 patients aged ≥18 years who tested positive for H. pylori were included. The experimental group (n=50) was given STT and probiotics, and the control group (n=50) was given only STT without probiotics for 14 days. Necessary follow-up was done six weeks after treatment. An independent sample t-test, chi-square test, and multiple regression analysis were used for statistical analysis. Result The odds of getting rapid urease test (RUT) negative results from positive were 2.06 times higher (95%CI= 0.95, 3.22, p=0.054) in the experimental group. ADRs were crucially towering in the control group (p=0.045) compared to the probiotics group. The probiotics group had a lower risk of having adverse effects by 0.54 times (95%CI=0.19, 0.84, p=0.032) than the control group. Conclusion Using probiotics and STT together to eradicate H. pylori may lower ADR and improve treatment adherence. It may also help terminate H. pylori infection more effectively. More research is required as H. pylori is very contagious and can ultimately cause life-threatening gastric cancer.


Introduction
Peptic ulcer disease (PUD) is described as hydrochloric acid-provoked damage of the epithelial lining of the gastrointestinal tract, arising predominantly in the stomach and duodenum called gastric ulcer (GU) and duodenal ulcer (DU), respectively [1,2].Australia-born Professor (Dr.) Barry James Marshall and Dr. John Robin Warren first reported in 1982 that the principal cause of PUD is infective disorders caused by curved gram-negative bacillus Helicobacter pylori, and later, in 2005, both obtained the Nobel Prize jointly for this discovery [3][4][5].Earlier, it was believed that regular ingestion of alcohol and tobacco, psychological multiple disorders, nonsteroidal anti-inflammatory drugs (NSAIDs), and lifestyle issues were principal causes of PUD [6][7][8].Marshall and Warren refuted the age-old concept of these causes of PUD [4,5,9].
It is known that H. pylori causes around 90-95% and 80-85% of DU and GU, respectively [4,10,11].Multiple studies reported that more than 50% of the globe's populace is infected with H. afpylori [12,13], with a considerable difference in the frequency among countries and the prevalence observed within a country [12][13][14][15].Nevertheless, all patients infected with H. pylori do not acquire PUD; only 10% of individuals develop PUD [10,16,17].H. pylori is responsible for the chronic infection that triggers a chronic inflammatory process in the superficial epithelial layer of the stomach; later, it causes several gastrointestinal disorders, including carcinoma [18][19][20][21].
Hooi et al. steered a systematic review and meta-analysis to make public that the African (70.1%; 95%CI, 62.6-77.7)and Australian (Oceania) (24.4%; 95%CI, 18.5-30.4)continents had the maximum and minimum pooled generality of H. pylori infection, respectively.The pervasiveness rate of H. pylori infection varies in different nations with the lowest in Switzerland (18.9%) and the highest in Nigeria (87.7%) [15].Congedi et al. published a scoping review that reported a decreased tendency of H. pylori infection among Australian citizens.Nevertheless, the scoping review could not confirm the infectious potential of H. pylori among susceptible clusters [22].Another systematic review conducted by Peleteiro et al. reported that the highest and lowest rates of H pylori infection were found in Mexico (90%) and Finland (13.1%), respectively [23].Although distinct differences are observed regarding H. pylori infection rates across the world, the general preponderance of H. pylori infection is around 50% of the worldwide populace [24,25].
The mortality rate because of H. pylori infection was considerably higher among the non-pharmacologically intervened group than in treated clusters (p<0.001)[26].It has been ascertained that the deaths among pharmacologically intervened and non-intervened clusters were 4.1-5.9%and 5.5-7.6%,respectively [26,27].H. pylori has been identified as the foremost jeopardizing factor in gastric carcinoma [28].Stomach cancer is considered the fifth leading malignancy and stands in third position for carcinoma-related mortality around the globe [29].It has been reported that 770,000 [30] to 800,000 [31] people passed away because of stomach cancer, and around 1.1 million fresh cases were seen in 2020 [30].The rate of frequency of stomach carcinoma is influenced by sex.H. pylori and related diseases affect male subjects two-fold more than female counterparts [30].It has been appraised that stomach cancer alone accounts for 7.7% of all carcinomarelated deaths [31].It is thus strongly advocated to eradicate H. pylori, especially in seropositive individuals with cytotoxin-associated gene A (CagA) [32][33][34][35][36]. CagA is an external cancer-stimulating protein for humans generated by some strains of H. pylori [34,37].
Australian Dr. Thomas J. Borody introduced the bismuth-based triple therapy containing bismuth and two antimicrobials.This was the first successful effort to manage H. pylori abolition [38,39].Goh et al. put forward the theory that the therapeutic intervention for H. pylori infection should include two antimicrobials (clarithromycin and amoxicillin) and a proton pump inhibitor (PPI) for two weeks [40].This combination is often called standard triple therapy (STT).Additionally, in those cases of H. pylori infection that are isensitive to penicillin (amoxicillin), it is replaced with metronidazole [40,41].Other than the mentioned antimicrobials, tetracyclines and fluoroquinolones are commonly used for H. pylori eradication [42][43][44].
The National Institutes of Health brought the first consensus report regarding eradicating H. pylori infection in 1994 [45].Subsequently, the European H. pylori Study Group endorsed STT as the leading therapeutic strategy during the first Maastricht conference in 1997 [46].Furthermore, multiple consensus guidelines published in the last two decades or more for the therapeutic intervention of H. pylori infection, such as Maastricht VI/Florence [47], the Toronto [48], Kyoto Global [49], Hong Kong recommendation [50], Taipei Global [51] and many more [52][53][54][55][56].
H. pylori is a gram-negative, spiral-shaped, microaerophilic, and highly infective pathogenic microbe; mounting antimicrobial resistance around the globe creates an alarming human health threat [57,58].Many treatment regimes and attempts at eradicating H. pylori were unsuccessful because of resistance [42,[59][60][61].H. pylori attained 100-1000 times more resistance to multiple antimicrobials when H. pylori were grown in the matching floating form or cholesterol [62][63][64][65].Another study revealed that H. pylori's resistance to clarithromycin was 22.2%.Amoxicillin and metronidazole resistance in H. pylori were 1.2% and 69.2%, respectively.The resistance patterns in the United States and Europe were similar and resistance to metronidazole was found to be the highest (50-79%) and the least resistance was to amoxicillin (equal to or lower than 5%) [66].Global resistance pattern against commonly prescribed antimicrobials for H. pylori infection eradication is high and ranges from 15-50% [67].Multiple studies reported that among eight South Asian countries (Bhutan, Bangladesh, India, Indonesia, South Korea, Nepal, Sri Lanka, and Thailand), the antimicrobial resistance of H. pylori patterns is much higher (98%).There is a high incidence of selfpurchasing of antimicrobials from community pharmacies, poor antimicrobial stewardship programs, and rapid alteration of geopolitical scenery and urbanization [68][69][70][71].One global systematic review and metaanalysis also reported that 15% of H. pylori possesses either primary or secondary resistance towards clarithromycin, metronidazole, and levofloxacin in practically all world regions [72].Nahar et al. reported from Bangladesh that H. pylori isolates were resistant to amoxicillin, clarithromycin, tetracycline, and metronidazole, and the resistance was determined to be 6.6%, 10%, 15%, and 77.5%, respectively [73].Over a decade after the study by Mahar et al. [72], Aftab et al. reported that H. pylori isolates in Bangladesh showed resistance to metronidazole, levofloxacin, and clarithromycin, and resistance rates were 94.6%, 66.1%, and 39.3%, respectively [74].
Our planet faces treatment difficulties regarding infectious diseases because of antimicrobial resistance to almost all available antimicrobials, which poses an enormous global health threat [75,76].Overall, antimicrobial resistance around the globe is the foremost public health issue, which equally affects H. pylori and related diseases because of the evolution of drug resistance.Moreover, H. pylori has been notified as the principal factor for gastric carcinoma with fatal consequences [77].In this antagonist situation, researchers developed multiple other regimens, such as bismuth-containing quadruple (hybrid therapy (HT) including a PPI, bismuth, metronidazole, and tetracycline), sequential (PPI plus amoxicillin followed by PPI, clarithromycin, and an imidazole), PCN (PPI, clarithromycin and nitroimidazoles), and concurrent or accompaniment (non-bismuth quadruple including PPI, clarithromycin, amoxicillin, and metronidazole) therapy to combat antimicrobial-resistant H. pylori infection beside SST [78][79][80][81][82][83].However, even with all these efforts, H. pylori eradication often failed because of resistance to multiple antimicrobials [84], such as amoxicillin, clarithromycin, metronidazole, and levofloxacin [41,85].Diarrhea, constipation, nausea, vomiting, epigastric pain, flatulence, metallic taste, and pain in the abdomen, especially in the epigastric region, are frequently occurring adverse drug reactions (ADRs) following SST therapy to combat H. pylori infection [86,87].Another study revealed that over 26% of the research participants had experienced ADRs [88].Among them, 85% had gastrointestinal issues, such as gastrointestinal distress, nausea, uncomfortable or infrequent bowel movements (typically less than three times per week), loose motions, stomach upset, an eating disorder frequently accompanied by unrestrained body weight loss, and headache [88,89].Another study revealed that over 45% of participants encountered principally gastrointestinal ADRs [90].Again, around 5% of patients were unable to continue therapeutic intentions because of profound ADRs, and approximately 3% of cases were unable to take less than 80% of medication because of ADRs.Total or partial discontinuation or medication adherence to H. pylori therapeutic intervention frequently leads to eradication failure and promotes antimicrobial resistance [91][92][93].Consequently, research analyses narrated that the foremost cause of H. pylori abolition failure is necessitous treatment incompliance that is related to STT-induced ADRs of prescribed drugs [88,94,95].
One metanalysis comprising 34 randomized control trials and over 9000 cases showed that the addition of Bifidobacterium-Lactobacillus-Saccharomyces and Bifidobacterium-Lactobacillus-based probiotics with diverse regimens of H. pylori extinction program resulted in minimizing ADRs and promoting medication adherence [96].Probiotics competitively restrain the growth of H. pylori in the stomach with their bacteriostatic effect.Additionally, probiotics improve gastrointestinal microbiome status [97].It has been reported that Saccharomyces boulardii, Bacillus licheniformis, Lactobacillus acidophilus, Bifidobacterium triple viable bacteria, and Bacillus subtilis dual viable bacteria are currently in clinical use in the management of H. pylori eradication program.These probiotics increase medicine adherence, cut back ADRs, especially antimicrobial-persuaded, mitigate the stomach mucosal chronic inflammation instigated by H. pylori, and increase the abolition rate of H. pylori when administered with various regimes as an adjuvant [97][98][99][100][101][102][103][104][105][106][107].

Problem statements of this study
Addressing the following problem statements can contribute significantly to developing more effective and patient-friendly H. pylori eradication therapies, ultimately improving treatment outcomes and reducing the global burden of H. pylori-associated diseases.

Efficacy Challenges in STT
One significant problem to address is the suboptimal extinction rate of H. pylori with the STT, consisting of a PPI, amoxicillin, and clarithromycin/levofloxacin.Despite being a widely employed treatment, the efficacy is compromised due to antimicrobial resistance and other factors [108].

Antibiotic-Related ADR
Another critical issue is the high incidence of ADRs associated with antibiotics, particularly clarithromycin and levofloxacin.Gastrointestinal disturbances, allergic reactions, and the development of antibiotic resistance are among the adverse effects that impact patient tolerance and compliance during H. pylori eradication therapy [109].

Impact of Dysbiosis on Treatment Outcome
The STT often disrupts the gut microbiota balance, leading to dysbiosis.This disturbance in the natural microbial community may contribute to prolonged recovery, increased susceptibility to infections, and other complications, necessitating exploring interventions to mitigate dysbiosis [110].

Need for Improved Treatment Strategies
Given the global rise in antibiotic resistance and the limitations of the STT, there is an urgent need to explore adjunctive therapies that can enhance eradication rates.Probiotics represent a promising avenue, but their specific role and mechanisms in improving treatment outcomes remain understudied and require comprehensive investigation [111].

Patient Non-Adherence and Treatment Failure
Poor patient compliance poses a significant challenge in H. pylori eradication therapy.Understanding the impact of probiotics on patient adherence and exploring strategies to improve compliance is crucial for achieving better treatment outcomes and reducing the risk of antibiotic resistance [94].

Variability in Probiotic Strains and Formulations
The variability in probiotic strains and formulations available in the market raises questions about their consistent effectiveness.Addressing the optimal selection, dosage, and duration of probiotic supplementation is essential to establish evidence-based recommendations for integration into H. pylori eradication regimens [112,113].

Objectives of the study
This study explores probiotic intervention for improving eradication rates and mitigating side effects in STT.It assesses the impact of probiotic supplementation on the eradication rate of H. pylori infection when combined with STT and evaluates the reduction in adverse effects of antibiotics of triple therapy, such as nausea, diarrhea, abdominal discomfort, metallic taste, headache, and joint pain and in determining the potential influence of probiotics on patient compliance and adherence to the prescribed treatment regimen.It also provides evidence-based recommendations regarding incorporating probiotics into STT for H. pylori extinction in clinical situations.

Materials And Methods
This was a prospective study conducted at the Department of Gastroenterology, Ship International Hospital, Dhaka, Bangladesh, from May to December, 2021.The study obtained ethical approval from the Institutional Review Board of Ship International Hospital (Formerly, Japan East West Medical College Hospital), Dhaka, Bangladesh (approval number: JEWMCH/IEC/01, dated March 5, 2021).Furthermore, written informed consent was obtained from all participants and the study adhered to the World Medical Association's Declaration of Helsinki, ethical principles for medical research involving human subjects.Additionally, research objectives and future publication plans were explained in detail to patients and guardians.

Inclusion Criteria
The following inclusion criteria defined the patients eligible for the study and provided a clear framework for selecting study participants: 1. Patients who were candidates for diagnostic endoscopy of the upper gastrointestinal tract (UGIT) with rapid urease test (RUT); 2. Patients who tested conclusively for H. pylori infection by RUT during the endoscopy; 3. Patients aged 18 years or older.

Exclusion Criteria
The following exclusion criteria ensured that the study population was well-defined and that the results were not confounded by factors that could affect the interpretation of the study outcomes: 1. Patients with a history of taking NSAIDs; 2. Patients with a previous history or report of hepatic, renal, or neoplastic diseases; 3. Pregnant women or lactating mothers; 4. Patients who received antibiotics or probiotics within four weeks before the study enrollment; 5. Patients with a known sensitivity or allergy to any drugs used in this study; 6. Patients who were unwilling to participate voluntarily in the study.

Sample size
A simple random probability sampling technique was practiced to allocate the patients to the investigational and control groups.The sample size was calculated at a 5% level of significance and a confidence interval of 95%.The sample size was calculated by the following formula: N= Z2pq/ e2.Using the formula, sample size was n=(1.96)2x(0.5) x (0.5)/ (0.05)2 = 384.However, our sample size was kept at 100 due to financial constraints and the COVID-19 pandemic (Figure 1).

FIGURE 1: Schematic diagram showing the methodology of this study.
Image credit: Sismita Sinha; with the premium version of BioRender [114] with the license number HM26K5BNK0

Sampling method
Simple random sampling was done from patients who underwent endoscopy of the upper gastrointestinal tract (UGIT) and tested positive for RUT.We used simple random sampling methods to ensure an unbiased representation of patients who undergo endoscopy of the upper UGIT and test positive for the RUT.

Questionnaire
Information on clinical history and adverse effects during triple therapy was collected using a questionnaire administered by the investigator.

Intervention
Patients meeting the inclusion criteria were randomly assigned into two different therapeutic intervention programs: (i) Group A (experimental group) (n = 50), which was given amoxicillin (1000 mg, two times a day), levofloxacin (500 mg once daily), rabeprazole (20 mg two times a day) with probiotics Lactobacillus plantarum LA 301, Lactobacillus salivarius LA 302 (once daily) for 14 days, and (ii) Group B (control group) (n = 50), which was given amoxicillin (1000 mg, two times a day), levofloxacin (500 mg once daily), and rabeprazole (20 mg two times a day for 14 days).
Follow-up was done six weeks after therapy completion.This follow-up time point allowed for assessing ADRs and abrogation rates of H. pylori following the intervention.During the follow-up, a second review endoscopy of UGIT with RUT was conducted to determine the status of H. pylori infection.During the followup, any ADRs experienced by the patients during the triple therapy were recorded.

Statistical analysis
No participants missed the follow-up after the intervention; thus, intention-to-treat analysis was introduced here.An independent sample t-test for continuous observation and a chi-square test for categorical observation were used to assess the demographic features.A multiple logistics regression model was used to estimate the risk of adverse effects in triple therapy with probiotics group compared to triple therapy without probiotics.The independent factors influencing the model >5% were used as covariates in the final regression model, i.e., age, sex, and history of hypertension, multiple comorbidities, smoking, and taking NSAIDs.Longitudinal multilevel mixed-effect models were used to assess the overall change in RUT after triple therapy with probiotics intervention.Models were adjusted with covariates (age, sex, history of morbidities, and smoking history) that affected the model R2 by 5% or more in the best-fitted regression model; additionally, time was used as a covariate to reduce the multicollinearity.For statistical analysis, Stata Statistical Software: Release 15 (StataCorp LLC, College Station, Texas, United States) and GraphPad Prism version 8.3.0 (Insightful Science, LLC, San Diego, California, United States) were used for graphical presentation.A p-value of p<0.05 was considered as significant.

Results
The participants in Group A (probiotics group) had an average age of 37.4 years, with a standard deviation of 13.4 years, while those in Group B (non-probiotics control group) had an average age of 38.3 years, with a standard deviation of 14.1 years.Regarding gender distribution, 52% of the probiotics group were male, and 48% were female.In the non-probiotics group, 54% were male, and 46% were female (Table 1).

NSAID: non-steroidal anti-inflammatory drugs
The breakdown of comorbidities in both groups showed a nearly identical distribution, covering conditions such as diabetes, hypertension, others, and multiple comorbidities.The category 'Nill' indicated participants with no comorbidities.Among the participants in the probiotics group, 22% were smokers, while in the nonprobiotics group, 18% were smokers.Additionally, 36% of the probiotics group reported consuming tea or coffee, compared to 32% in the non-probiotics group.Regarding betel nut consumption, 30% of participants in the non-probiotics group reported its intake, whereas only 16% of participants from the probiotics group had a history of betel nut consumption.The history of NSAIDs showed a similar distribution in both groups (Table 1).
Triple therapy with probiotics (N=50), n (%)  The history of past illnesses, including hematemesis and melena, exhibited no significant difference between the two groups (p=1.000).Personal habits such as smoking, alcohol consumption, tea/coffee consumption, betel nut use, and consumption of spicy and oily food also did not significantly differ between the two groups (p>0.05).The family history of PUD was reported by 32% of subjects in the probiotics group and 28% in the non-probiotics group, with no significant difference (p=0.663).The history of taking NSAIDs was also similar between the two groups (p=0.779)(Table 3).

TABLE 4: Findings of initial endoscopy
The p-value was estimated using the Chi-Square test.
When we assessed the endoscopy findings during the follow-up, it was detected that there was no significant variation between the two groups (Table 5).

TABLE 5: Findings of the review endoscopy during follow-up
The P-value was estimated by using the Chi-Square test.
Longitudinal multilevel was used to assess the overall change in RUT after triple therapy with probiotics intervention.The odds of RUT becoming negative from positive were 2.06 times higher (95%CI 0.95-3.22,p=0.054) in the probiotics group compared to the non-probiotics control group (Figure 2).When the association was checked with a non-parametric approach, ADRs were significantly higher in the nonprobiotics group (p=0.045)than in the probiotics group (Table 6).When the history of ADRs in the probiotics group was compared to the non-probiotics control group by the logistic regression model, it was observed that the probiotics group had a lower risk of having detrimental effects by 0.54 times (95%CI 0.19-0.84,p=0.032) (Figure 3).Upon stratifying the risk of ADRs based on antibiotic usage and employing a logistic regression model, the analysis revealed significantly lower odds of experiencing headaches in the group using PPI, antibiotics with probiotics, with an OR of 0.31 (95%CI 0.10-0.96,p=0.043) as depicted in Table 7 and Figure 4. Furthermore, in the amoxicillin group, the likelihood of GI upset and diarrhea was reduced by 0.33 and 0.12 times, respectively, in the presence of probiotics.For those study participants taking clarithromycin, the risk of diarrhea was 0.14 times lower in the group with probiotics compared to the group without probiotics.The analysis also indicated a 0.26 times lower risk of dyspepsia in the group with probiotics for individuals using metronidazole.Bismuth users exhibited a decreased risk of nausea and GI upset by 0.13 and 0.08 times, respectively.Moreover, probiotic users demonstrated lower odds of experiencing vomiting (OR=0.02),diarrhea (OR=0.12),flatulence (OR=0.24),and multiple joint pain (OR=0.24)when using levofloxacin as antibiotics (Table 7 and Figure 4).

Type of Authors,
He et al., 2022 [131] The use of antibiotics to treat H. pylori in the gut causes derangement in microbiota.Probiotics reduce the adverse effects of antibiotics, but their impact on allaying microbiota is not well-established The elimination rate of H. Pylori was almost similar in the placebo and probiotic groups.
Normal commensals suppressed following eradication were replaced by probiotics, and microbiota was progressively restored within two weeks.Adverse events were also less in the probiotic cluster.

H. pylori: Helicobacter pylori
Image credit: Rahnuma Ahmad; with the premium version of BioRender [114] with license number CH26GB4NBY.
Tables 9-10 give the list of studies reviewed on H. Pylori resistance in Bangladesh and low-and middleincome countries, respectively.

Study
Antibiotic resistance, especially of metronidazole, is well reported in people of developing countries, but data is scarce on the transfer of these resistant varieties through migrants.
The resistant variant was higher in migrants, with the majority from Bangladesh.Women born in the United Kingdom and previous treatment with nitroimidazole, metronidazole, and tinidazole were other risk factors.
Migrants affected by H. pylori from developing countries will likely have resistant varieties.
Khan et al., Treatment against H. pylori often fails due to resistance against clarithromycin.Alteration in genomic sequence is responsible for developing resistance, but data is limited in cases from Bangladesh.
A T-to-C transition mutation at position 2182 was found in every clarithromycin-resistant case that was analyzed.Eliminating H. pylori often fails due to antimicrobial resistance against commonly used antibiotics, but data is scarce in Bangladesh.
Metronidazole, followed by tetracycline, clarithromycin, and amoxicillin, were primarily resistant.
Higher resistance against common antibiotics in Bangladesh proves the need for extended monitoring.

Qumar et al., 2021 [152]
H. pylori infection is mostly prevalent in developing countries, and its treatment has become arduous due to the emergence of resistant varieties.The genotype of the predominant variety is not well documented in Bangladesh.
Isolated strains showed two separate varieties, e.g., HpAsia2 and HpEurope, where the prior one was more virulent.
The genotype of the bacteria, as well as environmental and host factors, are crucial to determine the clinical prognosis.

Khan et al. ,
2008 [153] Mutations in the 16S rRNA gene are thought to be responsible for clarithromycin-resistant H. pylori infection cases.Data from Bangladesh were limited.
In the tetracycline-resistant variety, none showed a mutation in the 16S rRNA gene.
Tetracycline resistance may also appear due to other causes rather than RNA mutation.Additionally, Grgov et al. [165] and Sýkora et al. [166], in their randomized control trials, revealed that probiotic treatment led to significantly higher eradication rates of 93.3% and 91.6%, respectively, compared to the control groups.On the contrary, Shavakhi et al. [167] and Hurduc et al. [168] observed no significant difference between the two treatment groups (Figure 6).Notes: Keywords were "Benefits," "Probiotics," "Helicobacter pylori," "Eradication," and "Triple therapy."Filters Applied: Randomized Controlled Trials.Indexed in PubMed.
No significant differences were observed in the initial and follow-up endoscopic findings regarding reflux esophagitis, erosive gastritis, gastric ulcer, and duodenal ulcer between the experimental (STT + probiotics) and control (only STT) group in the current study (Table 4) and (Table 5).One earlier study reported that H pylori extermination remedial measures escalate the possibility of reflux esophagitis, which is unrelated to previous records of esophagitis.Additionally, no considerable consequence can be comprehended regarding reflux-associated issues [172].One Japanese study reported that nearly 10% of H. pylori-positive cases develop reflux esophagitis after pharmacological intervention and successful eradication.This observation was principally noticed among cases with severe reflux-related symptoms before medical intervention.Meanwhile, after efficacious elimination, patients with H. pylori had definite improvement regarding pepticulcer-related manifestation.Nonetheless, the possibility of the reflux esophagitis evolvement remains [173].
Model analysis revealed positive clinical outcomes concerning H. pylori biomarker (RUT) after triple therapy with probiotics intervention.The odds of RUT becoming negative from positive were more than two-folds higher among the experimental group (SST + probiotics) in comparison to the control group (only STT) (Figure 2).One meta-analysis by Lu et al. comprising 21 RCTs reported that additional probiotics with STT do not show clinically better outcomes regarding H. pylori's extinction frequency when equated to the inactive medicinal agents [174].Akcam et al. reported similarly that no substantial confirmation was obtained about the abolition of H. pylori and the minimization of ADRs [170].Additionally, two more RCTs revealed no statistically significant differences observed between experimental (STT + probiotics) and control (only STT) [167,168].
In contrast, multiple studies reported that adding probiotics with standard therapy improves the degree of H. pylori eradication and diminishes antimicrobial-induced ADRs, especially gastrointestinal issues [170,175,176].Two more RCTs revealed that adding probiotic treatment led to considerably higher eradication rates [165,166].However, when the association was checked with a non-parametric approach, ADRs were significantly higher in the non-probiotics group than in the probiotics group (Table 6).Multiple earlier research published papers reported that the addition of probiotics with standard therapy improves the H. pylori eradication rate and diminishes ADRs [97,177].One meta-analysis comprising 13 RCTs and 2306 patients revealed that adding probiotics with H. pylori antagonist's regimen improves extinction percentages, parallelly lowers ADRs, and relieves most PUD-allied clinical indicators [171].Wang et al. reported that traditional triple therapy with probiotics, especially Bifidobacterium-Lactobacillus and Bifidobacterium-Lactobacillus-Saccharomyces therapy recuperates abolition proportions and reduces ADRs [96].Another RCT by Hauser et al. revealed that supplementation of probiotics with conventional triple therapy improves pharmacodynamic properties and decreases ADRs and patient compliance equally noticeably [178].
The logistic regression model analysis observed that the experimental group (probiotics) had a lesser risk of adverse effects when compared to the control group (without probiotics) regarding the risk of a history of ADRs in traditional triple therapy (Figure 3).Multiple studies reported that socio-anthropological differences between individual cases, history of PUD and non-communicable chronic disorders, tobacco and alcohol consumption, and the existence of hereditary issues affect extermination H. pylori treatment outcomes [95,179,180].Gebeyehu et al. reported that ADRs while receiving conventional triple therapy were dependent on the following changeable features: history of PUD over 21 days, location of dwelling, body mass index (BMI), consumption of alcohol, and long intervals between meals causing abdominal pain, when conducting bivariate and multiple logistic regression analysis [88].
The logistic regression model analysis revealed significantly lower odds of experiencing headaches in the group using PPI antibiotics with probiotics (Table 7 and Figure 4).Although the exact mechanism remains obscure, adding probiotics reduces migraine-associated headaches [181].Li et al. reported that supplementing probiotics with traditional triple therapy reduces headaches with or without vomiting [182].Additionally, both amoxicillin and clarithromycin antimicrobials receivers the possibility of GI issues, especially diarrhea, which were reduced with the supplementation of probiotics.Lactobacillus strains are well-known as noble probiotics and are most widely used among humans [183][184][185].Another study claimed probiotics benefit pharmacology in diverse intestinal disorders, including diarrhea [182].
Additionally, probiotics, especially Lactobacillus strains such as L. acidophilus, L. casei, L. salivarius, L. reuteri, L. johnsonii, and L. gasseri [186], possess the necessary pharmacodynamics to inhibit H. pylori [97,[186][187][188].This analysis also detected a lower risk of dyspepsia in the group with probiotics for those cases receiving metronidazole.Muresan et al. reported that Lactobacillus strains, mainly L. reuteri, minimize chronic dyspepsia [188].Bismuth salt receivers of the current study exhibited a decreased risk of nausea and GIrelated disorders.Bismuth subsalicylate (BSS) was permitted by the United States Food and Drug Administration (FDA) in 1939 for following clinical disorders such as diarrhea, heartburn, indigestions, nausea, and stomach upsets [189].Furthermore, BSS possesses pharmacological properties in minimizing GI distress and traveler's diarrhea [190].BSS also decreases the austerity and frequency of diarrhea and flatulence [189].Moreover, probiotic + levofloxacin recipients of the current study demonstrated lower odds of experiencing vomiting, flatulence, diarrhea, and multiple joint pain (Table 7 and Figure 4).In their research, Pugh et al. confirmed that probiotic therapeutic intervention frequently abolishes GI indicators, especially bringing up wind, biliousness, vomiting, passing intestinal gas, and loose motion [191].Furthermore, Sheffield et al. reported that adding probiotics with fluoroquinolones does not increase ADRs [192].
The principal findings of the current study are illustrated in Figure 7.

Limitations of the study
This study has limitations, including a small sample size, potentially compromising the generalizability of findings.Reliance on self-reported data raises the possibility of recall bias, impacting the accuracy of information.Additional limitations include the short follow-up duration and lack of assessment for publication bias.Careful consideration of these factors is crucial for a nuanced interpretation of the study's outcomes.

Conclusions
H. pylori causes persistent inflammation as well as infection in the stomach's superficial epithelial layer, leading to GI diseases such as cancer.Probiotics significantly enhance the condition of the gut microbiota and the bacteriostatic activity of probiotics hinders the replication of H. pylori in the stomach.Positive clinical effects for the H. pylori biomarker (RUT) during triple therapy with the probiotic intervention were found by model analysis in the current study.In contrast with the control group (only STT), the probability of going from positive to negative RUT was more than two times higher in the experimental group (SST + probiotics).In terms of the risk of ADRs, the logistic regression model analysis found that the experimental group (STT + probiotics) had a lower risk of side effects than the control group (only STT).Ongoing exploration is an urgent requirement among Bangladeshi patients, as H. pylori is highly infectious, easily transferable from person to person, and life-threatening microbes that may ultimately lead to gastric cancer.

FIGURE 2 :Adverse
FIGURE 2: The odds ratio of RUT risk becoming negative in the supplementation group compared to the group without probiotics.A multilevel mixed-effect model was used to analyze the OR of RUT.The analysis considered potential confounders that affected the model by >5% (age, sex, history of morbidities, and smoking history).RUT: rapid urease test Image Credit: Md.Ahsanul Haq

FIGURE 3 :
FIGURE 3: Risk of having adverse effects of triple therapy in the probiotics group compared to the non-probiotic group.The logistic regression model was used to estimate the p-value, and the regression model was adjusted by age, sex, history of hypertension, history of multiple comorbidities, history of smoking, and history of taking NSAIDs.NSAID: non-steroidal anti-inflammatory drugs Image Credit: Md.Ahsanul Haque.

FIGURE 4 :
FIGURE 4: Risk of adverse effects in triple therapy with probiotics group compared to triple medications excluding probiotics.No adverse impact was used as reference (1) for all measured events.The logistic regression model was used to estimate the p-value, and the regression model was adjusted by age, sex, history of hypertension, history of multiple comorbidities, history of smoking, and history of taking NSAIDs.NSAID: non-steroidal anti-inflammatory drug; PPI: proton pump inhibitor Image Credit: Md.Ahsanul Haq

FIGURE 5 :
FIGURE 5: Beneficial effects of adding probiotics to the standard triple therapy on patients with H. pylori infection.

FIGURE 6 :
FIGURE 6: Selected consequential papers showing the benefits of adding probiotics with standard therapy for Helicobacter pylori eradication.

FIGURE 7 :
FIGURE 7: Principal findings of the current study ADR: adverse drug reactionImage Credit: Rahnuma Ahmad; with the premium version of BioRender[114] with license number XA26G8WP6M

TABLE 1 : Demographic characteristics of the study participants
Data have been presented as n (%) except for age, which has been presented as mean±SD.An Independent sample t-test for continuous data and chisquare for categorical data was used to estimate the p-value.An unpaired t-test was conducted.

TABLE 2 : History of present illness of the study subjects
Data have been presented as n (%).A chi-square test was conducted.

TABLE 3 : History of past illness, personal history, family history of PUD, and history of drugs
Data have been presented as n (%).A chi-square test was conducted.PUD: peptic ulcer disease

Table 4
categorizes findings into reflux esophagitis, erosive gastritis, gastric ulcer, and duodenal ulcer, providing the respective percentages within each group.The p-values, derived from the Chi-Square test, are included to assess the statistical significance of differences in endoscopic findings between the two treatment groups.However, the results indicate no statistically significant variations in the prevalence of reflux esophagitis, erosive gastritis, gastric ulcer, or duodenal ulcer between the groups, as all the p-values surpass the conventional significance threshold of 0.05.Triple therapy with probiotics (N=50), n (%)Triple therapy without probiotics (N=50), n (%) p-value

TABLE 6 : Adverse Effects of Triple Therapy on the Study Subjects (N=100)
Notes: A Chi-Square Test was Conducted.

TABLE 7 : Risk of adverse effects of the antibiotics in triple therapy with probiotics compared to triple therapy without probiotics Multinomial
logistic regression was used to estimate the p-value, and the regression model was adjusted by age (category), sex (type, male and female), history of hypertension (category), history of multiple comorbidities (categorical), smoking history (categorical), history of taking NSAID (categorical).NSAID: non-steroidal anti-inflammatory drug; PPI: proton pump inhibitor 2024 Zaman et al.Cureus 16(3): e56283.DOI 10.7759/cureus.56283

TABLE 10 : Selected consequential papers on Helicobacter pylori resistance in low and middle- income countries.
Keywords were "Helicobacter Pylori," "Resistance," and "Low and middle-income countries."Filters Applied: Free full text, Meta-Analysis, Randomized Controlled Trial, Review, Systematic Review in the last five years.Indexed in PubMed.